Review
Prognostic factors in non-small cell lung cancer surgery

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Abstract

Aims

Complete surgical resection of primary tumours remains the treatment with the greatest likelihood for survival in early-stage non-small cell lung cancer (NSCLC). Although TNM stage is the most important prognostic parameter in NSCLC, additional parameters are required to explain the large variability in postoperative outcome. The present review aims at providing an overview of the currently known prognostic markers for postoperative outcome.

Methods

We performed an electronic literature search on the MEDLINE database to identify relevant studies describing the risk factors in NSCLC surgery. The references reported in all the identified studies were used for completion of the literature search.

Results

Poor pulmonary function, cardiovascular disease, male gender, advanced age, TNM stage, non-squamous cell histology, pneumonectomy, low hospital volume and little experience of the surgeon were identified as risk factors for postoperative outcome. However, with the exception of TNM stage and extent of resection, the literature demonstrates conflicting results on the prognostic power of most factors. The role of molecular biological factors, neoadjuvant treatment and adjuvant treatment is not well investigated yet.

Conclusions

The advantage of knowing about the existence of comorbidity and prognostic risk factors may provide the clinician with the ability to identify poor prognostic patients and establish the most appropriate treatment strategy. The assessment of prognostic factors remains an area of active investigation and a promising field of research in optimising therapy of NSCLC patients.

Introduction

Because of the relatively high incidence of postoperative complications, the hospital mortality, as well as disappointing long-term survival after surgical resection of non-small cell lung cancer (NSCLC), the appropriate selection of patients with NSCLC for pulmonary resection is a continuing challenge. It has been demonstrated that postoperative complications are associated with the extent of resection and the pre-existing comorbidity.1, 2 The occurrence of severe comorbidity is increasing owing to the rise of lung cancer incidence among the elderly as a consequence of improved life expectancy. Therefore, the decision on how to treat patients should not be based on tumour stage only, but also on comorbidity and performance status. As a result, it is important to be informed about the risk factors and how they affect postoperative morbidity, mortality, and long-term survival. Over the last decades, several studies have studied the impact of various factors on the early and late outcome. The prognostic factors can be categorized into clinical factors, tumour-related factors, and treatment-related factors.3 The purpose of this review is to provide an overview of the currently known prognostic markers for hospital mortality, morbidity, and long-term survival.

Section snippets

Pulmonary function

As tobacco use is associated with both chronic obstructive pulmonary disease (COPD) and NSCLC, the prevalence of COPD in patients with NSCLC is high.4 Underlying pulmonary disease consistently has been shown to be an important predictor of postoperative morbidity and hospital mortality. However, pulmonary function tests are not uniformly assessed, and as a consequence, not uniformly reported. The most valuable parameters reported for evaluation of pulmonary function are the absolute spirometric

TNM stage

For NSCLC, the concept of curability has been linked to resectability. The tumour-node-metastasis (TNM) staging system seeks to group patients with similar expected outcome based on potential for surgical treatment. The surgical-pathological TNM stage has been consistently found to be the most powerful predictive tool in prognostic assessment of survival in patients with NSCLC.3, 57, 58, 59, 60

Tumour (T) stage has been described as a prognostic factor in many series.37, 40, 61, 62, 63 Several

Type of resection

It is widely recognized that the risk of significant postoperative complications and hospital mortality increases with increasing extent of resection.77 Despite tremendous advances in operative techniques and perioperative and postoperative medical care, pneumonectomy has the highest complication and mortality rate of all elective pulmonary resections.8, 77, 78 Although operative morbidity and mortality seem to have declined, it is unclear whether pneumonectomy has become really safer over

Summary and conclusion

Identifying prognostic factors in operated early-stage NSCLC patients has been the focus of many investigations in order to improve outcome. Despite tremendous advances in perioperative and postoperative care, morbidity and mortality after pulmonary resection remain relatively high. Because of the heterogeneity of this disease and the variation in the surgical interventions and expertise, as well as the patient characteristics, the importance of prognostic factors varies from one study to

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